Extra Review

Adverse effect of using two or more oral contraceptives

- Breakthrough bleeding - Instruct clients to record duration and freq of brkthrgh bleed - Evaluate for possible pregnancy if two or more - menstrual periods are missed.

Monitoring of Danazol for patients who have endometriosis

- Decreases risk of breast cancer in women - Monitor for weight gain and swelling of ankles via daily weights

Adverse effect of topotecan (chemo drug)

- bone marrow suppression - GI discomfort for N/V use combination of antiemetic drugs before chemotherapy treatment begins - Alopecia

Adverse Effect of Dextroamphetamine

- hypervigilance as an example of CNS stimulation - insomnia, restlessness - tolerance and withdrawal include headache, nausea, vomiting, and muscle weakness - hypersensitivity, toxicity, cardiac problems like chest pain, high blood pressure, and dysrhythmias, hallucinations and paranoia, decreased appetite, weight loss, and growth suppression

Teaching a newly licensed nurse about effectively managing time

- organize according to client care needs and priorities - use time-saving strategies and avoid time wasters - time management is a cyclic process - save time by documenting nursing interventions as soon as possible after completion to facilitate accurate and thorough documentation. Grouping activities that are to be performed on the same client or are in close physical proximity to prevent unnecessary walking. Estimating how long each activity will take and planning accordingly. Mentally envisioning the procedure to be performed and gathering all equipment PRIOR to entering the client's room. Taking time to plan care and taking priorities into consideration. Delegating activities to other staff when client care workload is beyond what can be handled by one nurse. Enlisting the aid of other staff when a team approach is more efficient than an individual approach. Completing more difficult or strenuous tasks while energy level is high. Avoiding interruptions and graciously but assertively saying No to unreasonable or poorly timed requests for help. Setting a realistic standard for completion of care and level of performance within the constraints of assignment and resources. completing one task before beginning another task. Breaking large tasks into smaller tasks to make them more manageable. using an organizational sheet to plan care. using breaks to socialize with staff.

Preparing for a sterile dressing change

- remove dressing with CLEAN gloves - do not turn back on patient - inner surface of the sterile drape or kit except for that 1-inch border around the edges is the STERILE field to which other sterile items may be added - grasp the 1-inch border BEFORE donning sterile gloves. - touch materials ONLY with sterile gloves - any object held below the waist or above the chest contaminated - do not reach across or above a sterile field - do not turn your back on a sterile field - hold items to add to a sterile field at a minimum of 6 inches above the field - above waist

Identify four (4) indications for the placement of a Peripherally Inserted Central Catheter (PICC) and two (2) complications.

4 indications for the placement of a Peripherally Inserted Central Catheter (PICC) are administration of blood, long-term use of chemotherapeutic medications, long-term use of antibiotics, and long-term use of total parental nutrition (TPN) 2 complications of a Peripherally Inserted Central Catheter (PICC) are phlebitis at the insertion site and thrombosis or emboli due to an occlusion.

Functions of the Kidney

A WET BED A acid-base balance W water removal E ryhtropoesis (creating RBC) T toxin removal B blood pressure control E electrolyte balance D vitamin D activation

verifying placement of endotracheal tube

A chest x‑ray verifies correct placement of the endotracheal (ET) tube

A nurse is caring for a client experiencing opioid withdrawal. What manifestations should the nurse anticipate?

A client who is experiencing an opioid withdrawal (such as heroin withdrawal) would have the following manifestations: sweating (diaphoresis), rhinorrhea that progresses to piloerection, tremors, and irritability. Later manifestations include severe weakness, diarrhea, fever, insomnia, pupil dilation, nausea and vomiting, pain in muscles, pain in bones, and muscle spasms.

A client has been prescribed pregabalin for simple partial seizures. What is a contraindication for this medication?

A contraindication of pregabalin includes patients who are pregnant as this medication is a pregnancy category risk C and it can cause birth defects. Furthermore, those who are allergic to gabapentin are contraindicated from taking this medication since gabapentin and pregabalin are in the same drug category. A client being allergic to gabapentin can have the same anaphylactic reaction if that same client takes pregabalin.

NCLEX KEY WORDS

AVOID THESE WORDS SINCE THEY ARE ABSOLUTE NEVER ALWAYS MUST

Client education regarding ondansetron

Administer antiemetic such as ondansetron in combination with dexamethasone, granisetron, or metoclopramide before beginning chemotherapy

Planning care for a client who has tamoxifen

Advise clients to increase calcium and vitamin D intake. Advise clients to reduce bone loss with weight bearing exercises. Monitor for dysrhythmias and assess breath sounds. Encourage clients to perform monthly breast self examination, and schedule annual gynecologic and breast examinations and mammogram with the provider. Monitor CBC and calcium levels. Monitor fluid status. Advise female clients to use birth control during therapy

Potassium

Alkalosis - K is low Acidosis - K is high

Defense Mechanisms

Altruism Dealing with anxiety by reaching out to others Sublimation Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression Suppression Voluntarily denying unpleasant thoughts and feelings Repression Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness Regression Sudden use of childlike or primitive behaviors that do not correlate with the person's current developmental level Displacement Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation Reaction formation Overcompensating or demonstrating the opposite behavior of what is felt Undoing Performing an act to make up for prior behavior Rationalization Creating reasonable and acceptable explanations for unacceptable behavior Dissociation Creating a temporary compartmentalization or lack of connection between the person's identity, memory, or how they perceive the environment Denial Pretending the truth is not reality to manage the anxiety of acknowledging what is real Compensation Emphasizing strengths to make up for weaknesses Identification Conscious or unconscious assumption of the characteristics of another individual or group Intellectualization Separation of emotions and logical facts when analyzing or coping with a situation or event Conversion Responding to stress through the unconscious development of physical manifestations not caused by a physical illness Splitting Demonstrating an inability to reconcile negative and positive attributes of self or others Projection Attributing one's unacceptable thoughts and feelings onto another who does not have them.

APGAR

Appearance - color all pink, extremities blue, all blue Pulse - > 100, < 100, absent Grimace - cough, grimace, no cry Activity - active motion, some flexion, limp Respirations - strong cry, weak cry, absent

Umbilical Cord (AVA)

Artery - carry deoxygenated blood Vein - carry oxygenated blood Artery

Injury prevention for toddlers

Aspiration of foreign objects Small objects (grapes, coins, candy) that can become lodged in the throat should be avoided. Toys that have small parts should be kept out of reach. Age-appropriate toys should be provided. Clothing should be checked for safety hazards (loose buttons). Balloons should be kept away from toddlers. Parents should know emergency procedures for choking. Bodily Harm Sharp objects should be kept out of reach. Firearms should be kept in locked boxes or cabinets. Toddlers should not be left unattended with any animals present. Toddlers should be taught stranger safety. Burns The temperature of bath water should be checked. Thermostats on hot water heaters should be turned down to less than 49° C (120° F). Working smoke detectors should be kept in the home. Pot handles should be turned toward the back of the stove. Electrical outlets should be covered. Toddlers should wear sunscreen when outside. Drowning Toddlers should not be left unattended in bathtubs. Toilet lids should be kept closed. Toddlers should be closely supervised when near pools or any other body of water. Toddlers should be taught to swim. Falls Doors and windows should be kept locked. Crib mattresses should be kept in the lowest position with the rails all the way up. Safety gates should be used across the top and bottom of stairs Motor-vehicle injuries Infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height recommended by the manufacturer. Toddlers over the age of 2 years, or who exceed the height recommendations for rear-facing car seats, are moved to a forward-facing car seat. Safest area for infants and children is the backseat of the car. Do not place rear-facing car seats in the front seat of vehicles with deployable passenger airbags. Poisoning ●Exposure to lead paint should be avoided. ●Safety locks should be placed on cabinets that contain cleaners and other chemicals. ●The phone number for a poison control center should be kept near the phone. ●Medications should be kept in childproof containers, away from the reach of toddlers. ●A working carbon monoxide detector should be placed inthe home Suffocation ●Plastic bags should be avoided. ●Crib mattresses should fit tightly. ●Crib slats should be no farther apart than 6 cm (2.375 in). ●Pillows should be kept out of cribs. ●Drawstrings should be removed from jackets and other clothing.

What to do prior to planning teaching to client

Assess/monitor learning needs. Evaluate the learning environment. Identify learning style (auditory, visual, kinesthetic). Identify areas of concern (low literacy levels, pain, distractions). Identify available resources (financial, social, community). Identify developmental level. Determine physical and cognitive ability. Identify specific needs (visual impairment, decreased manual dexterity, learning challenges). Determine motivation and readiness to learn.

assisting with thoracentesis

Assist the provider with the procedure (strict surgical aseptic technique). Prepare the client for a feeling of pressure with needle insertion and fluid removal. Monitor vital signs, skin color, and oxygen saturation throughout the procedure. Measure and record the amount of fluid removed from the chest. Label specimens at the bedside, and promptly send them to the laboratory

Discuss five (5) general safety tips that should be provided to parents before discharge.

Before discharge, the RN should explain five general safety tips to the parents - never leave the newborn unattended with pets or small children, never place the newborn on his or her stomach to sleep during the first 6 months of life, never offer a newborn a pillow or a small blanket to sleep as this can cause a risk of aspiration, make sure that the mattress is firm and not a water bed, never have toys or bumper pads in a crib, and the crib's slats should be no more than 5-7 cm apart.

A nurse is caring for a non-verbal client following surgery. What are behavioral indicators of pain?

Behavioral indicators of pain for a non-verbal client following surgery include the following: facial expressions such as grimacing or wrinkled forehead, body movements such as restlessness and guarding, moaning or crying, decreased attention span. Other indicators of pain include increased blood pressure, increased pulse rate, and increased respiratory rate.

substance use disorders - symptoms of the newborn

CNS: High‑pitched, shrill cry; incessant crying; irritability; tremors; hyperactivity with an increased Moro reflex; increased deep‑tendon reflexes; increased muscle tone; disturbed sleep pattern; hypertonicity; convulsions Metabolic, vasomotor, and respiratory findings: Nasal congestion with flaring, frequent yawning, skin mottling, retractions, apnea, tachypnea greater than 60/min, sweating, temperature greater than 37.2° C (99°F) Gastrointestinal: Poor feeding; regurgitation (projectile vomiting); diarrhea; excessive, uncoordinated, constant sucking

identifying CSF leak

CSF leakage from the nose and ears can indicate a basilar skull fracture ("halo" sign: yellow stain Surrounded by blood on a paper towel; fluid tests positive for glucose)

manifestations of severe dehydration

Capillary refill greater than 4 seconds ■Tachycardia present, and orthostatic blood pressure can progress to shock ■Extreme thirst ■Very dry mucous membranes and tented skin ■Hyperpnea ■No tearing with sunken eyeballs ■Sunken anterior fontanel ■Oliguria or anuria

Hypoglycemia

Cold and Clammy = give me some candy

teaching strategies for child with ADHD

Collaborate with the school nurse. Allow more time for testing. Place in classroom that has order and consistent rules. Offer verbal instruction combined with visual cues. Plan academic subjects in the morning. Include regular breaks. Provide for small classroom settings or work groups

A nurse is caring for a 12-year-old anorexia nervosa. What are common laboratory and diagnostic testing results commonly associated with anorexia nervosa?

Common laboratory results associated with anorexia nervosa are hypokalemia, anemia, leukopenia, possible increased liver enzyme levels, and possible elevated cholesterol, elevated BUN due to dehydration, abnormal blood glucose level, and increased HCO3 due to metabolic alkalosis. Diagnostic testing results associated with anorexia nervosa are abnormal thyroid function tests, ECG changes such as prolonged QT interval, decreased bone density, low Body Mass Index (BMI), abnormal urinalysis, and abnormal results from the following screening tools: eating disorder inventory, body attitude test, diagnostic survey for eating disorders, eating attitude test.

Pink and Frothy Sputum Indicates

Congestive Heart Failure AND Pulmonary Edema (life-threatening)

Baby-friendly care

Considers the infant a family member ◯Holds the infant face‑to‑face (en face position), maintaining eye contact ◯Assigns meaning to the infant's behavior and views this positively ◯ Identifies the infant's unique characteristics and relates them to those of other family members. ◯ Names the infant, indicating bonding is occurring ◯ Touches the infant and maintains close physical proximity and contact ◯ Provides physical care for the infant, such as feeding and diapering ◯ Responds to the infant's cries ◯ Smiles at, talks to, and sings to the infant

Group and family meetings - recognizing task roles in the group

Coordinator - Clarifies ideas and suggestions that have been made within the group (task) Evaluator - Examines group plans and performance , measuring against group standards and goals (task) Recorder - records things Initiator - Outlines the tasks at hand for the group and proposes methods for solution (task) Orienter - Maintains direction within the group keeps focus on task conpletion(task)

Discharge teaching: newborn care

Crying - inform the parents that the newborns cry when they are hungry, overstimulated, wet, cold, hot, tired, bored, or need to be burped. The mother should not feed the newborn every time he or she cries. It is okay to let newborn cry for short periods of time Quieting Techniques - swaddling - close skin contact - nonnutritive sucking with a pacifier - rhythmic noises to stimulate utero sounds - movement (a car ride, vibrating chair, infant swing, rocking newborn) - placing a newborn on his stomach across a holder's lap - en face position for eye contact (12 inches apart) in the same place - stimulation Sleep - do not have newborn sleep with parents (think SIDS) place newborn in crib or bassinet - keep environment quiet and dark at night - bring a newborn out into the center of action in the afternoon - bathe newborn right before bedtime - last feeding at 2300 - awake, can be placed on the abdomen to promote muscle development for crawling. supervision required. - keep small night-light on to avoid to turn on bright lights, speak softly, handle gently - do proper positioning and holding of newborn - After an initial bath, newborn face, diaper, and skin folds are cleaned daily. 2-3 times a week with mild soap - bathing by immersion is not done until umbilical cord has fallen off and circumcision has healed

Schilling Test

Determines diagnosis of pernicious anemia how well does one absorbs Vitamin B12

Use of crutches

Do not alter crutches after fitting. ●Follow the prescribed crutch gait. (3 pt gait for nonbearing leg) ●Support body weight at the hand grips with elbows flexed at 30°. ●Position the crutches on the unaffected side when sitting or rising from a chair

Drawing Insulin (RN)

Draw air into NPH insulin (cloudy) Draw air into regular insulin (clear) Draw up regular (clear) Draw up NPH (cloudy)

What are expected findings in a client with alcohol use disorder? What are withdrawal symptoms?

EFFECTS OF INTOXICATION ●Effects of excess: Slurred speech, nystagmus, memory impairment, altered judgment, decreased motor skills, decreased level of consciousness (which can include stupor or coma), respiratory arrest, peripheral collapse, and death (with large doses) ●Chronic use: Direct cardiovascular damage, liver damage (ranging from fatty liver to cirrhosis), erosive gastritis and gastrointestinal bleeding, acute pancreatitis, sexual dysfunction WITHDRAWAL MANIFESTATIONS ●Manifestations include abdominal cramping; vomiting; tremors; restlessness and inability to sleep; increased heart rate; transient hallucinations or illusions; anxiety; increased blood pressure, respiratory rate, and temperature; and tonic-clonic seizures. ●Alcohol withdrawal delirium can occur 2 to 3 days after cessation of alcohol. This is considered a medical emergency. Manifestations include severe disorientation, psychotic manifestations (hallucinations), severe hypertension, cardiac dysrhythmias, and delirium. Alcohol withdrawal delirium can progress to death Expected findings in a client with alcohol use disorder include the following: relaxation, decreased social anxiety, and stress reduction. Withdrawal symptoms include abdominal cramping, vomiting, tremors, restlessness, and insomnia, tachycardia, increased blood pressure, increased respiratory rate, increased temperature, and tonic-clonic seizures

nursing actions when assisting ECT

EKG! invasive so informed consent beforehand (witness) 30 mins prior to the procedure, administer IM injection of atropine sulfate to decrease secretions that can cause aspiration and to counteract any effects such as bradycardia methohexital or propofol via IV bolus the sux is then administerd monitor V/S, mental status, oxygen saturation (so 100% oxygen is used) following ECT, patients become alert within 15 mins

teaching about ileostomy

Educate the client regarding dietary changes and ostomy appliances that can help manage flatus and odor. Foods that can cause odor include fish, eggs, asparagus, garlic, beans, and dark green leafy vegetables. Buttermilk, cranberry juice, parsley, and yogurt help to decrease odor. Foods that can cause gas include dark green leafy vegetables, beer, carbonated beverages, dairy products, and corn. Chewing gum, skipping meals, and smoking can also cause gas. Yogurt, crackers, and toast can be ingested to decrease gas. After an ostomy involving the small intestine is placed, instruct the client to avoid high‑fiber foods for the first 2 months after surgery, chew food well, increase fluid intake, and evaluate for evidence of blockage when slowly adding high‑fiber foods to the diet. Proper appliance fit and maintenance prevent odor when the pouch is not open. Filters, deodorizers or a breath mint can be placed in the pouch to minimize odor while the pouch is open. Provide opportunities for the client to discuss feelings about the ostomy and concerns about its effect on the client's life. Encourage the client to look at and touch the stoma. Refer the client to a local ostomy support group

A mass casualty incident (MCI) has destroyed the town next to you. Your acute care hospital is preparing for multiple victims. Discuss the four (4) categories of triage during an MCI.

Emergent (Class 1) - Normally colored red in the triage system, this category is the highest priority during a MCI. This is given to clients who have life-threatening injuries but have a high possibility of survival once they become stabilized. Such injuries include a tension pneumothorax and lacerations that led to amputations. Urgent (Class II) - Normally colored yellow in the triage system, this category is the next highest priority given to the clients who have major injuries that are not yet life-threatening and can wait for 45-60 minutes before treatment begins. Such injuries include open fractures. Nonurgent (Class III) - Normally colored green in the triage system, this is the next priority given to clients who have minor injuries that are not life-threatening and do not need attention right away. They can wait the longest. Such injuries include abrasions and closed fractures. Expectant (Class IV) - Normally colored black in the triage system, this is the lowest priority given to clients who are not expected to survive and are allowed to die naturally. Comfort measures are given to these clients. Examples include a severe head injury with decreasing respirations.

Priority action for a nurse who accidentally gave the wrong medication to the patient - after the nurse took the patient's blood pressure, the next action should be?

Evaluate clients' responses to medications, and document and report them. Use knowledge of the therapeutic effect and common side and adverse effects of medications to compare expected outcomes with actual findings. Identify side and adverse effects, and document and report them. Report all errors, and implement corrective measures immediately

ergonomic principles - reposition patient safely

Evaluate each situation and use an algorithm to determine the safest method to transfer or move the client. Answer these questions: Can the client bearweight? Can she assist? Is she cooperative? Determine the client's ability to help with transfers (balance, muscle strength, endurance, use of a trapeze bar). Evaluate the need for additional staff or assistive devices (transfer belt, hydraulic lift, sliding board). Assess and monitor the use of mobility aids (canes, walkers, crutches). Include assistance or mobility aids in the plan of care for safe transfers and ambulation.

manifestations of MS

Fatigue, especially of the lower extremities Pain or paresthesia Diplopia, changes in peripheral vision, decreased visual acuity Uhthoff's sign (a temporary worsening of vision and other neurological functions commonly seen in clients who have or are predisposed to MS, just after exertion or in situations where they are exposed to heat) Tinnitus, vertigo, decreased hearing acuity Dysphagia Dysarthria (slurred and nasal speech) Muscle spasticity Ataxia or muscle weakness Nystagmus Bowel dysfunction (constipation, fecal incontinence) Bladder dysfunction (areflexia, urgency, nocturia) Cognitive changes (memory loss, impaired judgment) Sexual dysfunction

A nurse is caring for a postpartum client who is breastfeeding her newborn. Identify five (5) teaching points to discuss with the client regarding the postpartum infection, mastitis.

Five teaching points to discuss with the client regarding mastitis are as follows: wash hands carefully and thoroughly before breastfeeding the newborn, allow nipples to air-dry, have proper positioning of the newborn during breastfeeding and proper latching-on techniques (latching onto the nipple and areola, empty the breasts with each feeding to prevent milk stasis and mastitis, continue to breastfeed frequently especially on the affected side and to use a breast pump if the affected breast becomes painful.

Discuss care of the client following a cleft lip and palate repair.

Following a cleft lip repair, nursing care to the client includes the following: position the infant on his or her back and in an upright position or on his or her side during the postoperative period, apply elbow restraints (which should be frequently removed to assess the skin and let the arm move), use normal saline, water, or diluted hydrogen peroxide to clean the incision site, apply antibiotic ointment if it is prescribed by the health care provider, gently aspirate secretions of the mouth and the nasopharynx to prevent any respiratory distress. Following a cleft palate repair, nursing care to the client includes the following: change the infant's position periodically to facilitate drainage and breathing, maintain IV fluids until infant can eat and drink, clear liquid diet for first 24 hour, avoid placing straw, tongue depressor, hard pacifier, rigid utensils, hard-tipped sippy cups, or suction catheters in the mouth, apply elbow restraints, use a face mask to deliver oxygen.

Hypoglycemia - signs and symptoms (HE IS TIRED)

HE headache I irritability S sweating (diaphoresis) T tachycardia I same as the first i R restlessness E excessive hunger D dizziness

Standard Precautions

HIV Hep A, B, C

Hyperglycemia

Hot and Dry = sugar high

During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies?

I will replace any IV catheter when I suspect contamination during insertion."

ICP and Shock

ICP High BP Low RR Low HR Shock Low BP High RR High HR

Preventing infant abduction

Identification (using two identifiers) is applied to the newborn immediately after birth by the nurse. It is an important safety measure to prevent the newborn from being given to the wrong parents, switched, or abducted. The newborn, mother, and mother's partner are identified by plastic identification wristbands with permanent locks that must be cut to be removed. Identification bands should include the newborn's name, sex, date, and time of birth, and mother's health record number. The newborn should have one band placed on the ankle and one on the wrist. In addition, the newborn's footprints and mother's thumb prints are taken. The above information is also included with the footprint sheet. Each time the newborn is given to the parents, the identification band should be verified against the mother's identification band. All facility staff who assist in caring for the newborn are required to wear photo identification badges. The newborn is not to be given to anyone who does not have a photo identification badge that distinguishes that person as a staff member of the facility maternal‑newborn unit. Many facilities have locked maternal‑newborn units that require staff to permit entrance or exit. Some facilities have a sensor device on the ID band or umbilical cord clamp that sounds an alarm if the newborn is removed from the facility

A client arrives at the emergency room and tells the nurse that she has been doubling her daily dose of carbamazepine daily so that she can be cured faster. The nurse understands that she is now at risk for which of the following complications? Polyuria and dilute urine, Leukopenia, anemia, and thrombocytopenia, Increase in risk for blood clotting, Rapid heartbeats, and anxiety

If the client has been doubling her daily dose of carbamazepine daily, the client is now at risk for leukopenia, anemia, and thrombocytopenia - symptoms of blood dyscrasias.

Explain the steps involved in providing an intermittent enteral feeding.

In providing an intermittent enteral feeding, here are the steps. First, prepare the formula and a 60-mL syringe. Next, remove the plunger from the syringe and then hold the tubing above the instillation site. Open stopcock from tubing and insert barrel of the syringe with end up, fill that syringe with 40-50 mL of formula. Hold the syringe high for formula to empty by gravity and refill the syringe until the amount of feeding is instilled. To prevent clogging of the tube, follow up with at least 30 mL of tap water for flushing.

A nurse is caring for a client following gastrectomy surgery. What should information regarding prevention of dumping syndrome the nurse provide to this client?

Information regarding prevention of dumping syndrome should include the following: advise the client to report to the provider if the client has tachycardia, hypotension, and abdominal pain. Other signs include fullness, faintness, diaphoresis, palpitations, nausea, cramping pain, diarrhea, weakness, and syncope. Furthermore, lie down after meals, do not drink with meals, limit fluid intake, avoid milk, sweet, and sugars, eat a high-protein, high-fat, low-carb diet.

oral glucose tolerance test

Instruct the client to consume a balanced diet for 3 days prior to the test and fast for 10 to 12 hr prior to the test. The technician will obtain a blood specimen for a fasting blood glucose level at the start of the test. The client then consumes a specific amount of glucose. The technician obtains blood samples at 30 min, 1 hr, 2 hr, 3 hr, and sometimes 4 hr after the client consumes glucose. Assess clients for hypoglycemia throughout the procedure.

Home care for a patient with Cystic Fibrosis

Instruct the family about ways to provide CPT and breathing exercises. ●Promote regular provider visits. ●Emphasize the need for up‑to‑date immunizations and a yearly influenza vaccine. ●Teach about diet and ways to increase calorie intake. ●teach indications of infection and when to call the provider. ●Teach parents about ways to manage chronic illness in children. ●Promote regular physical activity. ●Encourage the family to participate in a support group and use community resources. Provide information on respite care. ●Identify specific needs based on the client's developmental level. For example, older adolescents are at a higher risk for depression due to the emotional and physical effects of cystic fibrosis. ●Provide home palliative care for the child or adolescent in the terminal stages of CF.

Fat Soluble Vitamins

KADE Vitamins K, A, D, E

Contact Precautions (MRS. WEE)

M multi resistant organism R respiratory infection, RSV S skin infection (scabies, shigella), Herpes Simplex W wound infection E enteric such as C-Diff E eye infection such as conjunctivitis

Airborne Precautions (MY CHICKEN HEZ TB)

MY measles CHICKEN chicken pox (varicella) Hez Herpes Zoster TB Tuberculosis

nursing interventions for client who used PCP in toxic doses

Maintain a safe environment to prevent falls; implement seizure precautions as necessary. ◯Provide close observation for withdrawal manifestations, possibly one‑on‑one supervision. Physical restraint should be a last resort. ◯Orient the client to time, place, and person. ◯Maintain adequate nutrition and fluid balance. ◯Create a low‑stimulation environment. ◯Administer medications as prescribed to treat the effects of intoxication or to prevent or manage withdrawal. This can include substitution therapy. ◯Monitor for covert substance use during the detoxification period

When triaging a group of clients...

Maslow's hierarchy of needs A, B, C systemic before local (life before limb) acute before chronic urgent before nonurgent actual problems before the risk of problems listen and do not assume recognize and respond to trends vs. transient (expected) findings medical emergencies before transient findings

Contraindicated Vaccinations for Pregnant Women

Measles Smallpox Mumps Rubella Varicella

Peritoneal Dialysis Nursing Care

Monitor vital signs frequently during initial dialysis of clients in a hospital setting. Monitor serum glucose level (dialysate contains glucose, a hypertonic solution). Record the amount of inflow compared to an outflow of dialysate. Monitor the color (should be clear, light yellow) and amount (should equal or exceed the amount of dialysate inflow) of outflow. Monitor for signs of infection (fever; bloody, cloudy, or frothy dialysate return; drainage at access site) and for complications (respiratory distress, abdominal pain, insufficient outflow, discolored outflow). Check the access site dressing for wetness (risk of dialysate leakage) and exit‑site infections. Warm the dialysate prior to instilling. Avoid the use of microwave ovens, which cause uneven heating. Adhere to the times for infusion, dwell, and outflow. Maintain surgical asepsis of the catheter insertion site and when accessing the catheter. Keep the outflow bag lower than the client's abdomen (drain by gravity, prevent reflux). Reposition the client if inflow or outflow is inadequate. Carefully milk the peritoneal dialysis catheter if a fibrin clot has formed. Provide emotional support to the client and family

Maintaining client confidentiality

Nurses must not disclose clients' information to unauthorized individuals OR family members who request it in person or by telephone or email. Nurses should ask any person inquiring about a client's status for the code and disclose information only when the individual can give the code. So if something arises, have that family member or individual know to contact the CLIENT to get information. Nurses cannot do that!

nursing actions for hyperbilirubinemia

Observe the skin and mucous membranes for jaundice. Monitor vital signs. Set up phototherapy if prescribed. Maintain an eye mask over the newborn's eyes for protection of corneas and retinas. Keep the newborn undressed. For a male newborn, a surgical mask should be placed (like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. Be sure to remove the metal strip from the mask to prevent burning. Avoid applying lotions or ointments to the skin because they absorb heat and can cause burns. Remove the newborn from phototherapy every 4 hr, and unmask the newborn's eyes, checking for inflammation or injury. Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. Check the lamp energy with a photometer per facility protocol. Turn off the phototherapy lights before drawing blood for testing. Observe the newborn for effects of phototherapy. Bronze discoloration: not a serious complication Maculopapular skin rash: not a serious complication Development of pressure areas Dehydration: poor skin turgor, dry mucous membranes, decreased urinary output Elevated temperature Encourage the parents to hold and interact with the newborn when phototherapy lights are off Monitor elimination and daily weights, watching for evidence of dehydration. Check the newborn's axillary temperature every 4 hr during phototherapy because the temperature can become elevated. Feed the newborn early and frequently, every 3 to 4 hr.This will promote bilirubin excretion in the stools. Encourage continued breastfeeding of the newborn. Supplementation with formula may be prescribed. Maintain adequate fluid intake to prevent dehydration. Reassure the parents that most newborns experience some degree of jaundice. Explain hyperbilirubinemia, its causes, diagnostic tests, and treatment to parents. Explain that the newborn's stool contains some bile that will be loose and green. Administer an exchange transfusion for newborns who are at risk for kernicterus

nursing care of newborn who has hypoglycemia or SGA

Obtain blood by heel stick for glucose monitoring. An asymptomatic at‑risk newborn who has a blood glucose level 25 mg/dL in the first 4 hr, or less than 35 mg/dL from 4 hr to 24 hr of age, should be offered oral feedings to increase levels to greater than 45 mg/dL. Initiate IV dextrose for a symptomatic newborn. Provide frequent oral and/or gavage feedings or continuous parenteral nutrition early after birth to treat hypoglycemia. Monitor the neonate's blood glucose level closely per facility protocol. Monitor IV if the neonate is unable to feed orally. Maintain skin‑to‑skin contact to treat hypothermia

What is one common adverse effect of an inhaled anticholinergic, such as ipratropium? Provide two (2) points for a nurse to include when teaching the client on this medication.

One common adverse effect of an inhaled anticholinergic, such as ipratropium, is dry mouth. Two points for a nurse to include when teaching the client on this medication is to sip fluids and to suck on sugar-free hard candies to help alleviate dry mouth. Also, teach the client to rinse his or her mouth after inhaling the medication to remove the unpleasant taste of the medication.

PRE-eclampsia - signs and symptoms

P proteinuria R rising blood pressure E edema (swelling) especially facial swelling

Appendicitis

Pain in the Right Lower Quadrant (RLQ)

Cholecystits

Pain in the Right Upper Quadrant (RUQ)

Nursing care following TURP

Postoperative treatment for a TURP usually includes placement of an indwelling three‑way catheter. The urinary catheter drains urine and allows for instillation of a continuous bladder irrigation (CBI) of normal saline (isotonic) or another prescribed irrigating solution to keep the catheter free from obstruction. The rate of the CBI is adjusted to keep the irrigation return pink or lighter. For example, if bright‑red or ketchup‑appearing (arterial) bleeding with clots is observed, the nurse should increase the CBI rate. If the catheter becomes obstructed (bladder spasms, reduced irrigation outflow), turn off the CBI and irrigate with 50 mL irrigation solution using a large piston syringe or per facility or surgeon protocol. Contact the surgeon if unable to dislodge the clot. Record the amount of irrigating solution instilled (generally very large volumes) and the amount of return. The difference equals urine output. ◯ The catheter has a large balloon (30 to 45 mL). The catheter is taped tightly to the leg, creating traction so that the balloon will apply firm pressure to the prostatic fossa to prevent bleeding. This makes the client feel a continuous need to urinate. Instruct the client to not void around the catheter as this causes bladder spasms. Avoid kinks in the tubing. Monitor vital signs and urinary output. Administer/provide increased fluids. Monitor for bleeding (persistent bright‑red bleeding unresponsive to increase in CBI and traction on the catheter or reduced Hgb levels) and report to the provider. Assist the client to ambulate as soon as possible to reduce the risk of deep‑vein thrombosis and other complications that occur due to immobility. Administer medications. Analgesics (surgical manipulation or incisional discomfort) Antispasmodics (bladder spasms) Antibiotics (prophylaxis) Stool softeners (avoid straining) When the catheter is removed, monitor urinary output. The initial voiding following removal can be uncomfortable, red in color, and contain clots. The color of the urine should progress toward amber in 2 to 3 days. Instruct the client that expected output is 150 to 200 mL every 3 to 4 hr. The client should contact the provider if unable to void

The parents of a toddler are concerned about the risk of home poisonings. What prevention education should the nurse provide?

Prevention education that a nurse should provide regarding risk of home poisonings should include the following: keep houseplants and cleaning agents such as bleach out of reach from the toddler, check and remove any sources of led such as paint chips, place paint and gasoline, in locked cabinets, keep medication in child-proof containers and locked up in cabinets, properly dispose of medications that are expired.

Sickle Cell Crisis

Prioritize Pain and Fluids oxygenate first though!

A nurse notes late decelerations on the fetal monitor. What priority actions should the nurse take?

Priority actions that the nurse should take are as follows: place the client in a side-lying position, insert an IV catheter or if it is already in place to increase the IV fluid, discontinue or stop oxytocin infusion, administer oxygen via mask 8-10 L/min nonrebreather, elevate legs, notify provider, and prepare for caesarean section birth.

A nurse is caring for a client that exhibits signs and symptoms of aspiration during their enteral feeding. What is a priority intervention the nurse should carry out?

Priority intervention the nurse should carry out for a client that exhibit signs and symptoms of aspiration during enteral feeding include first stopping the feeding, then turn the patient to the side for positioning, suction the airway, provide oxygen if indicated or needed, monitor vital signs for temperature rising or rapid respiratory rate, monitor for decreased oxygen saturation, auscultate breath sounds for increased congestion, notify the provider, and obtain a chest x-ray.

tyramine diet

REMOVE THE FF FROM THE DIET - ripe avocados or figs - liver - fermented or smoked meats - dried or cured fish - most cheeses - some beer - some wine - protein supplement What is ok... cottage cheese and cream cheese yogurt

A nurse is obtaining a rectal temperature. When should rectal temperatures be avoided?

Rectal temperatures should be avoided if the patient has a blood disorder that can cause prone to bleeding such as Hemophilia. Furthermore, rectal temperatures should be avoided in those who have low platelet count, those who have rectal disorders, and those who have diarrhea

What is a nurse's responsibility regarding advance directives?

Regarding advance directives, it is the nurse's responsibility to offer written instructions regarding advance directives especially to clients who do not have one or never had one, document the client's advance directives status, ensure that the advance directives are current and came from the client's current decision, identify that the client's choice is a priority when a conflict between the family and the client arises. The same can be said between the client and provider. Lastly, the nurse is responsible to inform all members of the health care interdisciplinary team (physical therapy, dietitian, etc.) about the client's advance directives.

A nurse is caring for a child prescribed an MRI (magnetic resonance imaging). What information should be provided to the child's parents regarding this test?

Regarding this test, parents should know that the MRI is not painful to the child, it is not invasive, and it doesn't use radiation so the parents can be with the child in the same room. If the child has any metal materials such as jewelry or bobby pins, they should be removed because of the strong magnet that can interfere with those materials in the room. If contrast is used, ask the parents if the child is allergic to shellfish. The child has to keep still throughout the test.

monitoring a client receiving a blood transfusion

Remain with the client for the first 15 to 30 min of the infusion (reactions occur most often during the first 15 min) and monitor vital signs and rate of infusion per facility policy. OLDER ADULT CLIENTS: Assess vital signs every 15 min throughout the transfusion because changes in pulse, blood pressure, and respiratory rate can indicate fluid overload, or can be the sole indicators of a transfusion reaction. Older adult clients who have cardiac or renal dysfunction are at an increased risk for heart failure and fluid‑volume excess when receiving a blood transfusion. Administer the blood transfusion over 2 to 4 hr for older adult clients. Withhold administration of other IV fluids during blood product administration to prevent fluid overload. Notify the provider immediately if indications of a reaction occur

Droplet Precautions (SPIDERMAN)

S sepsis, scarlet fever, streptococcyl pharyngitis P pertussis (whooping cough), Parvovirus B19 (fifth disease, red slap one), Pneumonia I influenza (flu) D dipthertia E epiglottis R rubella M Mumps , meningitis, mycoplasma, meningeal pneumonia AN andenovirus

Medications affecting blood pressure: clonidine

S/E - sedation, drowsiness, rebound hypertension, dry mouth

A client comes to clinic exhibiting symptoms of agitation, sweating, confusion, hyperreflexia, tachycardia, and ataxia the day after starting a new prescription for citalopram. The nurse suspects which problem: Hypertensive Crisis, Serotonin Syndrome, Tyramine Reaction, Panic Attack

Serotonin Syndrome

A home care nurse is evaluating safety risks in the home. What are some factors that can contribute to a client's injury risk?

Some factors that can contribute to a client's injury risk include frayed cords, cords that are on the floor or not against a wall behind furniture, lack of grab bars near the toilet or in tub or shower, not much lighting near the stairs, inside, or out of the home, lack of shower chair in the shower or bathtub for older adults, presence of throw rugs or loose carpets that can cause the client to trip, lack of carbon monoxide detectors and smoke alarms.

Tricyclic Antidepressants (TCA's) - adverse effects

T Thrombocytopenia C Cardiac (MI, arrhythmias, stroke) A Anticholinergic (tachycardia, urinary retention, dry mouth, blurry vision) Seizures

facilitating sibling acceptance of the newborn

Take the sibling on a tour of the obstetric unit. Encourage the parents to do the following. Let the sibling be one of the first to see the infant. Provide a gift from the infant to give the sibling. Arrange for one parent to spend time with the sibling while the other parent is caring for the infant. Allow older siblings to help in providing care for the infant. Provide preschool‑aged siblings with a doll to care for

IUD teaching

The device must be monitored monthly by clients after menstruation to ensure the presence of the small string that hangs from the device into the upper part of the vagina to rule out-migration or expulsion of the device Best used by women in a monogamous relationship due to the risks of STIs 99% effective maintain effectiveness for 1-10 yrs causes risk of pelvic inflammatory disease and ectopic pregnancy

A nurse is caring for an adult male client following a lumbar spinal surgery. Which of the following findings would indicate a fluid volume deficit? A. Serum Hematocrit 45% B. BUN 30 mg/dL C. Urine specific gravity 1.020 D. Serum Sodium 138 mEq/L

The following findings that would indicate a fluid volume deficit are BUN 30.

A nurse is caring for a client in the postpartum phase. How should the nurse assess fundal height following delivery?

The nurse should assess fundal height following delivery by palpating the fundus with the fundus being firm, midline with the umbilicus and at the level of the umbilicus.

The nurse is assessing the weight of an adolescent in the second trimester of pregnancy and notes that she has lost weight since her last prenatal visit 4 weeks ago. What would the nurse include in the client education?

The nurse should include the following client education regarding nutrition in pregnancy: young adolescents are advised not to be on a diet during pregnancy, not having enough weight gain in pregnancy can cause an increased risk of SGA or small for gestational-age in newborns, high risk of illness and death in newborns, high risk of having premature newborns, and recommended weight gain for the second trimester of pregnancy is 2-4 lb per month.

What is the purpose of the Patient Self Determination Act (PSDA)?

The purpose is to ask in a mandatory manner all clients being admitted if they have an advance directive, a document that communicates a client's wishes regarding treatment during end-of-life.

A nurse is caring for a client in Buck's traction. What is the purpose of this type of traction?

The purpose of Buck's traction is to immobilize a hip or knee fracture and to diminish muscle spasms before a client goes into surgery. It is also used to prevent contractures.

A client has been given instructions about rifampin. Which of the statements indicate that the client has the correct understanding of the instructions. "I will take the medication with food". "I can occasionally have a beer". "My urine may be orange". "I need to take Vitamin B6, daily"

The statement about rifampin is correct when the client says, "My urine may be orange."

Risk factor for taking aspirin

This risk factor can cause ulcers if a client takes aspirin.

A client is prescribed rosuvastatin (Crestor). Identify three (3) adverse effects and lab values the nurse should monitor.

Three adverse effects of rosuvastatin include muscle pain and tenderness (myopathy), rhabdomyolysis, and hepatotoxicity. Lab values that the nurse should monitor include creatinine kinase (CK), cholesterol, HDL, LDL, triglycerides, and liver enzymes such as AST and ALT.

A nurse has obtained a blood sample from a child with hemophilia. What action should the nurse take to prevent bleeding?

To prevent bleeding, the nurse should administer factor replacement (Factor VIII for Hemophilia A) by IV infusion. Furthermore, once a blood sample has been obtained, apply pressure for five minutes, avoid taking rectal temperature, and avoid unnecessary skin punctures. Also, the nurse should educate the client to avoid sharp edges, falls, contact sports, and rough playing.

nursing care for a client who has conduct disorder

Use a calm, firm, respectful approach with the child. ●Use modeling to show acceptable behavior. ●Obtain the child's attention before giving directions. Provide short and clear explanations. ●Set clear limits on unacceptable behaviors and be consistent. ●Plan physical activities through which the child can use energy and obtain success. ●Assist parents to develop a reward system using methods, such as a wall chart or tokens. Encourage the child to participate. ●Focus on the family and child's strengths, not just the problems. ●Support the parents' efforts to remain hopeful. ●Provide a safe environment for the child and others. ●Provide the child with specific positive feedback when expectations are met. ●Identify issues that result in power struggles. ●Assist the child in developing effective coping mechanisms. ●Encourage the child to participate in group, individual, and family therapy. ●Administer medications, such as antipsychotics, mood stabilizers, anticonvulsants, and antidepressants; monitor for side effects

VEAL CHOP

V Variable Decels --> Cord Compression --> reposition E Early Decels --> Head compression --> A ccelerations --> Patient is OKAY, monitor L Late Decels --> Placenta insufficiency --> turn off oxytocin, turn patient to left side, administer oxygen, increase IV fluid, call doctor

VCHIPS (skin infections as contact precautions)

V varicella zoster C - Cutaneous diptheria H - Herpes simplex I - Impetigo P - Pediculosis S - Scabies, Staphylococcus

A bed-bound client needs to be repositioned. What guidelines should the nurse follow to prevent personal injury?

When a bed-bound client needs to be repositioned, the nurse should do the following to prevent personal injury: know the hospital's policies for safe lifting and handling, have at least one staff personnel help with positioning clients especially when moving up a client up in bed, plan these positioning activities ahead of time and ask others to help, remove any obstacles prior to positioning the patient (e.g. extra pillows on the bed), explain the process to the client before positioning, explain role to staff members before positioning, safest way to lift client is assistive device, have very good posture when lifting, exercise regularly to have arms, legs, back and abdominal muscles strengthened, have neck and head remain in a straight line with the pelvis, and ensure that movements of moving clients are smooth.

What safety precautions should be implemented when a client reports an allergy to latex?

When a client reports a latex allergy, safety precautions that should be implemented include having the entire health team aware that the client has a latex allergy before any tasks or procedures are given, having the staff use latex-free gloves, latex-free equipment and supplies, and having a latex-free cart supplied with latex-free items. If the client will have a procedure in the operating room, the procedure should be done first thing in the morning and there should be a sign in the door written as "latex-free".

nursing interventions for a client who is in restraints

adults - 4 hrs the provider has to reassess the client if the client has to be in restraints for 24 hrs complete documentation every 15-30 min check for neurovascular status, toileting, v/s, food, and fluid offered, check behavior too

actions to prevent increasing intra-abdominal pressure

avoid coughing, straining, and lifting objects greater than 10 lb

Carbamazepine - adverse effects

bone marrow suppression anemia leukocytosis thrombocytopenia assess lab values of hemoglobin and platelets

Adverse Effects of Beta Blockers (-lol)

contraindicated with asthma patients so coughing bradycardia can cause heart failure - weight gain, edema, fatigue, SOB can mask hypoglycemia so look for manifestations of that orthostatic hypotension

teaching for pt who has newly inserted pacemaker

do not go through MRI machines carry pacemaker ID card all times wear the sling when out of bed do not raise the arm above shoulder for 1-2 Wks take pulse daily at the same time (let the doctor know if less than pacemaker rate) report signs for dizziness, fainting, fatigue, weakness, chest pain, hiccupping, palpitations, SOB, weight gain no contact sports or heavy lifting for 2 months avoid direct blows to the site resume sex as desired, avoid positions that put stress never place items that generate a magnetic field - garage door openers, burglar alarms, strong magnets power transmitters, large stereo speakers, cell phones (microwave ovens are ok) let the dentist know (contra to MRI and diathermy officials at the airport (TSA) should be notified of clients who have pacemakers, the security device should not affect pacemaker functioning, airport security should not place wand detection devices over the pacemaker

Metabolic Acidosis

from the Ass (diarrhea)

Metabolic Alkalosis

from the mouth (vomit)

Autonomic Dysreflexia - Interventions

head of bed at 90 degrees (high fowlers) loosen restrictive clothing assess for bladder distention --> quick urine cath administer antihypertensive drugs

Toxicity: Reverse Agents

heparin - protamine sulfate warfarin - phytonadione (vitamin K) digoxin/digitalis - digibind/digoxin immune FAB opiods - nalaxone ammonia - lactulose alcohol withdrawal - BENZOS acetaminophen - acetylcysteine Benzos - flumazenil iron - deferoxamine lead - succimer magnesium sulfate - calcium gluconate cyanide poisoning (smells like almond) - methylene blue curare - edrophonium

Pertussis

highly contagious paroxysmal coughing vomiting whooping inspiration

Safe application of physical restraints

make sure physician knows about this (restraint order) and visits the client within 1 hour of the client receiving physical restraints restraint should never interfere with treatment should not be SNUG (2 fingerwidths btwn) fit properly and be as discreet as possible be easy to remove or change (every 2 hours for toileting and checking neurovascular status) only used 4 hrs for adults. for physician prescription, it can go up to 24 hrs.

Glomerulonephritis - priority intervention

monitor blood pressure others: restrictions on fluid sodium protein potassium

Earliest sign of Compartment Syndrome

paresthesia (numbness and tingling on fingers

Complications of central vascular catheters

phlebitis occlusion mechanical dislodgement

physiological adaptations due to labor

postpartum chill changes in fluid

referral for client who has alcohol use disorder

rehab!

Interactions with Ginseng

rosiglitazone repaglinide metformin acarbose

cromolyn (mast cell stabilizer)

take it 15 mins before exercise or exposure to allergen

priority intervention for heat stroke

think A, B, C

for SATA

think of each option as T or F

Moro Reflex

when startled by noise legs will FLEX arms and hands will EXTEND

Client education regarding Rifampin

• Inform clients of expected orange color of urine, saliva, sweat and tears o Do not wear contact lenses while you are taking rifampin. This medicine may discolor your tears, which could permanently stain soft contact lenses. wear glasses instead • Inform clients regarding manifestations of anorexia, fatigue, and malaise and instruct them to notify the provider if they occur (hepatotoxicity) • Instruct clients to avoid alcohol • Instruct clients to monitor and report for fever, diarrhea, abdominal pain, or bloody stool (discontinue medications as this is pseudomembranous colitis).

Rinne Test

• Place vibrating tuning fork firmly against mastoid bone • Have client state when he can no longer hear the sound • Length of time that client heard the sound (BC) • Move turning fork in front of the ear canal • Have client state when he can no longer hear the tuning fork sound • Note the length of time (AC) • AC sound longer than BC

Contraindication to administering digoxin

• Pregnancy (Category Risk C) • Disturbances in the ventricular rhythm including o Ventricular Fibrillation (V-Fib) o 2nd degree AV block o 3rd degree AV block o Ventricular Tachycardia (V-Tach)

Adverse Effects of nasal decongestants

• Rebound congestion (to solve this make it short-term via 3-5 days and taper use) • CNS stimulation • Vasoconstriction